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The patient is a 68-year-old man, a pedestrian in an automobile accident, who suffered a traumatic brain injury, secondary to subarachnoid, subdural, and parenchymal hematomas. The patient had a prolonged course in the intensive care unit, where a tracheostomy was performed and a percutaneous endoscopic gastrostomy tube was placed. Complications included ventilator-associated pneumonia, gram-negative bacteremia, and a multidrug-resistant urinary tract infection. No family members or authorized medical decision maker could be located. The patient remained in a bed-bound unresponsive state and, after a 3-month hospital stay, was discharged to a nursing home.
Two days later the patient was readmitted in septic shock; blood culture grew extended-spectrum β-lactamase Escherichia coli, and the patient was treated with imipenem. Again, every attempt was made to locate the patient's family or a decision maker, but none could be found. An ethics consult was called, and, after deliberation, the patient's code status was changed to “Do Not Resuscitate.” After 1 additional month in the hospital, the patient was discharged to a nursing home again.
Approximately 3 weeks later, the patient was transferred back to the hospital after Pseudomonas was detected in his sputum. Blood cultures on admission grew multidrug-resistant Acinetobacter, which was sensitive only to polymyxin. The patient remained unresponsive. The attending physician did not want to administer a last-line antibiotic to a patient with an extremely poor prognosis for meaningful recovery.
Questions: Can we ethically justify withholding last-line antibiotics in this patient? Can we protect use of this antibiotic so that bacteria don't become resistant to it, with the hope that it will work in subsequent patients with substantially better chances of positive outcomes? What would you do? Please give us your thoughts in our Reader Remarks area below, and then see how medical ethicists responded to these questions.